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      Craniofacial Reconstruction by a Cost-Efficient Template-Based Process Using 3D Printing

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          Summary:

          Craniofacial defects often result in aesthetic and functional deficits, which affect the patient’s psyche and wellbeing. Patient-specific implants remain the optimal solution, but their use is limited or impractical due to their high costs. This article describes a fast and cost-efficient workflow of in-house manufactured patient-specific implants for craniofacial reconstruction and cranioplasty. As a proof of concept, we present a case of reconstruction of a craniofacial defect with involvement of the supraorbital rim. The following hybrid manufacturing process combines additive manufacturing with silicone molding and an intraoperative, manual fabrication process. A computer-aided design template is 3D printed from thermoplastics by a fused deposition modeling 3D printer and then silicone molded manually. After sterilization of the patient-specific mold, it is used intraoperatively to produce an implant from polymethylmethacrylate. Due to the combination of these 2 straightforward processes, the procedure can be kept very simple, and no advanced equipment is needed, resulting in minimal financial expenses. The whole fabrication of the mold is performed within approximately 2 hours depending on the template’s size and volume. This reliable technique is easy to adopt and suitable for every health facility, especially those with limited financial resources in less privileged countries, enabling many more patients to profit from patient-specific treatment.

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          A plastic surgery application in evolution: three-dimensional printing.

          Three-dimensional printing represents an evolving technology still in its infancy. Currently, individuals and small business entities have the ability to manufacture physical objects from digital renderings, computer-aided design, and open source files. Design modifications and improvements in extrusion methods have made this technology much more affordable. This article explores the potential uses of three-dimensional printing in plastic surgery.
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            Autogenous bone graft: basic science and clinical implications.

            No single biomaterial is optimum for every craniomaxillofacial application. Instead, surgeons should consider the advantages and disadvantages of each alternative in a given clinical situation, and select the material with lowest overall cost and morbidity, and the highest likelihood of success. Autogenous bone is still considered the gold standard for most applications; it becomes vascularized and osseointegrates with surrounding bone, thus minimizing the risk of infection, dislodgement, or break-down. Limitations include added operative time for graft harvest, donor site morbidity, graft resorption, molding challenges, and limited availability, especially in the pediatric population. Numerous alternatives to bone graft have become available to address these limitations; unfortunately, most of these products are expensive, do not osseointegrate, and have unpredictable biologic activity. Understanding the physiologic behavior of autogenous bone graft can help clarify the indications for its use and provide a conceptual framework for achieving the best possible outcome when this alternative is chosen.
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              Analyses of the factors influencing bone graft infection after delayed cranioplasty.

              Several factors influencing bone graft infection after delayed cranioplasty are analyzed in order to reduce the occurrence of infection. For about 10 years, from March 1995 to February 2005, delayed cranioplasty was performed for 206 cases. The cases comprised 124 males and 82 females. Age distribution of the patients ranged from 6 months to 79 years old. The mean postoperative follow-up period was 1834 days. Autogenous bone, which was preserved in 100% ethanol at -20 degrees C and autoclaved before operation, was used in 54 patients. Polymethylmethacrylate (PMMA) was used in 55 patients. Custom-made PMMA was used in 3 patients. Custom-made titanium mesh was used in 77 patients. Custom-made ceramics (Alumina-ceramics 10 cases and hydroxyapatite 7 cases) was used in 17 patients. Autoclaved and autogenous bone graft and PMMA have a significantly high rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection. Alumina-ceramic has a merit that it has sufficient strength, however the number of cases using custom-made ceramics including alumina-ceramic was relatively small, and thus we cannot find significant differences in infection rate compared with that of other materials. There was no statistically significant difference in the bone graft infection rate among four categories of preceding diseases; cerebrovascular diseases, head trauma, infectious diseases, and brain tumour. Autoclaved and autogenous bone grafts and PMMA have a significantly higher rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection.
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                Author and article information

                Journal
                Plast Reconstr Surg Glob Open
                Plast Reconstr Surg Glob Open
                GOX
                Plastic and Reconstructive Surgery Global Open
                Wolters Kluwer Health
                2169-7574
                17 November 2017
                November 2017
                : 5
                : 11
                : e1582
                Affiliations
                From the [* ]Clinic for Oral and Cranio-Maxillofacial Surgery, University Hospital of Basel, Basel, Switzerland; []Medical Additive Manufacturing Research Group, Hightech Research Center, Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland and []Department of Hand Surgery, Kantonsspital Baselland, Liestal, Switzerland.
                Author notes
                Bilal Msallem, MD, DMD, Clinic for Oral and Cranio-Maxillofacial Surgery, University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland, E-mail: bilal.msallem@ 123456usb.ch
                Article
                00017
                10.1097/GOX.0000000000001582
                5732683
                d795b48b-d7aa-49e0-af0f-737812d0113f
                Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 19 July 2017
                : 3 October 2017
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